Form I

Application for grant of permission for undertaking repair/renovation in the prohibited
area and construction/reconstruction/repair/renovation in the regulated area of
protected monuments or archeological site & remains declared as the national importanceunder
Ancient Monuments and Archaeological Sites and Remains Act, 1958

1.

Name of the Applicant :

2.

Adress of Applicant

(a) Present address

(b) Premanent address

3.

Name of owner(s)

1.
2.
3.
4.

5.
6.
7.
8.

9.
10.

4.

Address of owners

(a) Present Address

(b) Permanent Address

1.

1.

2.

2.

5.

Wether the property is owned by individual/jointly:

6.

Wether the property is owned by Government/Public Sector Undertaking/Private Sector Undertaking/Firm ( if so details to be furnished with complete address and phone numbers)

7.

(a)
Locality of the proposed construction

(b)
full details plot number, etc.

8.

Name of the nearest monument or site :

(a) Locality

(a) Taluk

(a) District

(a) State

9.

Distance of the site of construction related activities from the protected boundary of the monument:

(In
Meters)

(a) Distance from the main monument:

(In Meters)

(b) Distance from the protected boundary wall of the monument:

(In
Meters)

10.

Nature of work proposed

Repair Renovate Construction Re-Construction

11.

Details of the work proposed (furnish complete details with drawings of building / structure)

(i) Number of storeys

(ii) Floor area (storey-wise)

1. Ist floor
2. IInd floor
3. IIIrd floor
4. IVth floor
5. Vth floor

6. VIth Floor and above

(iii) Height (excluding mumty, parapet, water-storage tank, etc.)

(iv) Height (including mumty, parapet, water-storage tank, etc.)

(v) basement, if any proposed with details

12.

Purpose of the proposed work :

Residential Commercial Institutional Public Community

13.

Approximate date of the commencement of the proposed works :

14.

Approximate duration for completion of the proposed work :

15.

Maximim height of the existing modren buildings in the close vicinity of :

(a) near the Monument :

(In
Meters)

(a) near the site of construction related activity :

(In
Meters)

16.

Wether the monument is located within the limits of :

Corporation Municipality Nagar Panchayat Village Panchayat

17.

Does any Master Plan/zonal development plan/layout plan approved by concerned local authorities exists for the city/town/village:

Yes No

18.

Status of the modern constructions in the vicinity of the monument and the proposed site of construction/reconstruction :

19.

Open space/park/green area close to the protected monument / protected area :

20.

Wether any road(s) exists between the monument and the site of construction/reconstruction

Yes No

21.

Remarks/additional information, if any :

I
declare that the above information is correct. I also undertake to observe the provisions
of the Ancient Monuments and Archaeological Sites and Remains Act, 1958 as amended
by the, the Ancient Monuments and Archaeological Sites and Remains (Amendment and
Validation) Act, 2010 and the rules made there under.

Place :

Date :

Signature of Applicant

Note :

If the Application is on the behaf of the organizaton / firm, the signature should
be of the head of that organization / firm.

Enclose photographs showing the monument and the existing modren constructions.

Google Earth Images of the area under reference showing the monument and the site
of construction related activities.

Enclose ownership documents duely attested by an authorised officer of the Government.

In case of repair/renovation a report from a duly authorised/licenced architect
to be submitted by the applicant.

Attachments to be uploaded

(i)Documents
(Zip/Rar File)

(a)Ownership documents
( S.No. 5)

(b)Authorization letter
( S.No. 5)

(ii)Building Plans
( Pdf File )

(a)Building Plans
(S.No. 11)

(iii)Photographs (Zip/Rar File)

(a)Photos of the proposed site and construction in its vicinity
( S.No. 15b)

(b)Photos of the nearest monument and construction in its vicinity
( S.No. 15a)

(c)A google image showing the nearest monument and the proposed site of construction
(S.No. 8)